12th May 2025
The National Institute for Health and Care Excellence (NICE) has no mandate from the government to include environmental issues in its recommendations. And its discussions with the public shows that people will not accept being denied treatments judged to be better than what is currently available and cost-effective on environmental grounds.
This is frustrating when the climate and nature crisis is the major threat to health and is getting rapidly out of control. Radical change is needed at every level, including in the advice that NICE provides to the NHS and health professionals.
Then I remember that I’ve been here before.
In the 1990s I was a member of something called the Rationing Action Group (RAG) that believed “that rationing in health care is inevitable and that the public must be involved in the debate about issues relating to rationing.” (1) By rationing we meant “exclusion or denial of a service.” The NHS could not afford to do everything, and it should have a transparent, evidence-based method for rationing. We laid out a long agenda to inform the debate in the BMJ in June 1996 and published a list of the 22 members, including patients, clinicians, public health experts, ethicists, a religious leader, policy people, health economists, a television presenter, and others. (1)
The dying Tory government of the time insisted that there was no rationing in the NHS. Everybody working in the NHS knew different. The timing of RAG may have been fortunate. The Labour party won the election with a huge majority in May 1997, and I remember that an adviser to the new government attended some of the RAG meetings. But the new government initially stuck to the fiction that there was no rationing in the NHS.
In January 1999 the government got itself into a terrible tangle over sildenafil (Viagra), the new treatment for erectile dysfunction. (2) The government worried that if doctors could prescribe the drug to all men with erectile dysfunction then the NHS would be bankrupted. The drug would have to be, er, rationed, but how? Civil service potentates assembled to decide how often British couples might have sex (daily, weekly, monthly?) and whether some causes of erectile dysfunction were more worthy of qualifying for the drug. The criteria they came up with made, said the BMJ, “no sense on clinical, equity, or cost effectiveness grounds” and caused a great backlash. (2)
That fiasco was probably the major factor leading to the birth of NICE later in 1999. It would decide whether new treatments should be available in the NHS based on whether the treatment was more effective than treatments already available in the NHS and whether it was cost effective. Treatments might be more effective than what was currently available and yet still not be made available in the NHS on grounds of cost. This was rationing, but the chair of NICE insisted it wasn’t. This was political doublethink.
Cost was assessed using quality adjusted life years (QALYs), an imperfect measure. The biggest problem with QALYs is not the technical difficulties in measuring cost, the number of years added by the treatment, and the quality of those years, all difficult, but the philosophical objection that we all have a different idea of what constitutes “quality.” If running is my passion then paralysis in my legs will drastically reduce the quality of my life, whereas if listening to music is my passion the impact of the paralysis will be much less on the quality of my life.
Despite the difficulties of the measurements and the philosophical objections, NICE continues to use QALYs, and I support them in doing so. A “good enough” measure is better than no measure (a statement itself open to philosophical objections), and I think that NICE should be able to develop a “good enough” measure of the environmental impact of a new treatment. Such measures are already being developed. (3) I would like to see them being used not just to measure the environmental impact of the treatment but also to deny it being available if it passed a particular level of environmental impact.
The lesson from this historical comparison of incorporating cost into decisions might be that eventually NICE will come round not only to incorporating environmental measures in its decisions but to use them to deny some treatments that might be more effective than others available and cost effective. I suggest, however, that the necessity to use environmental measures is more urgent than ever it was for cost. The government could increase funding for the NHS, as it has done dramatically since 1999, and the worst that could happen is that the NHS would go bust, a political but not an existential disaster.
Now we are talking about the NHS along with all other enterprises continuing to pour greenhouse gases into the atmosphere, and if we don’t limit those emissions soon we will render the planet uninhabitable to humans. The need for NICE to use environmental measures is both more important and more urgent than it ever was for cost issues.
Richard Smith is the Chair of the UK Health Alliance on Climate Change and a former editor of the BMJ
1 New B. The rationing agenda in the NHS. BMJ 1996; 312 :1593 doi:10.1136/bmj.312.7046.1593
2 Chisholm J. Viagra: a botched test case for rationing If it leads to a proper debate about rationing the decision on sildenafil will not be entirely bad. BMJ 1999; 318 :273 doi:10.1136/bmj.318.7179.273
3 Walpole, S. C., Weeks, L., Shah, K., Cresswell, K., Mesa-Melgarejo, L., Robayo, A., & Greaves, F. (2023). How can environmental impacts be incorporated in health technology assessment, and how impactful would this be? Expert Review of Pharmacoeconomics & Outcomes Research, 23(9), 975–980. https://doi.org/10.1080/14737167.2023.2248389